By the time the opioid epidemic was dominating headlines, it was already out of control. So how did the epidemic sneak up on the United States, and what is being done at the state and federal levels to combat the issue?
The doors of Cherokee Health Systems’ addiction clinic aren’t even fully open—the office space is still being finished—but already the number of patients being treated is growing by word of mouth as providers send patients and patients tell friends and family members.
The clinic, run by Mark McGrail, MD, director of Addiction Medicine Services for Cherokee, is located in Knoxville, Tennessee—a state that had more opioid prescriptions being written in 2015 than there were residents. According to data from IMS Health,1 Tennessee had the second-most opioid prescriptions written per capita in 2015, or 1.18 per person.
“When you see the stats, it’s alarming in and of itself—just the sheer volume of opioids that are prescribed in the state,” McGrail said. He added that those prescriptions are often not used correctly or make their way into someone else’s hands. It’s not uncommon for these individuals to then graduate onto heroin.
In 2015, there were more than 33,000 overdose deaths that involved an opioid, according to a report published in the CDC’s Morbidity and Mortality Weekly Report.2 From 2014 to 2015, opioid death rates increased by 15.6%, most likely driven by the abuse of prescription and illicit drugs, such as fentanyl and heroin.2
How Did We Get Here?
Although the opioid epidemic has dominated headlines for the last 2 years, Vermont has been struggling with it throughout the 2000s, according to Barbara Cimaglio, deputy commissioner of the Vermont Department of Health. As early as 2001, the state started a specialty opioid treatment program, but with only 1 provider prescribing methadone for the whole state, people were traveling very long distances to get treated.
“There are many reasons that people typically think about how the epidemic really got out of control,” said Kelly J. Clark, MD, MBA, DFASAM, president-elect of the American Society of Addiction Medicine.
There is America’s societal focus on treating issues with pills and the need to be without pain, she said. There is also the marketing for these drugs that downplays the threat of addiction3 and an emphasis on patient satisfaction surveys in the United States that ultimately lead to physicians prescribing more opioids. According to Clark, physicians have to be better trained to say “no” to their patients.
“It’s very easy for us to give a prescription rather than deal with the biopsychosocial issues that have led to patient complaints or to simply say, ‘this pill won’t help you, so I can’t give it to you,’” she said.
Another issue is that opioid pills are inexpensive to pharmacy benefit managers (PBMs). As such, patients pay cash for these medications and they don’t hit the PBM claims system at all, which may have helped to mask the growing epidemic. Clark also reiterated the point McGrail made, that often people are using opioids that were not prescribed to them. Clark is based in Kentucky, and in Appalachia, the people typically don’t have health insurance. If these individuals experience pain, they can’t take a day off from working in the mines; instead, they take an opioid pill from a family member so they can go to work, she said.
Combatting the Opioid Epidemic
As a public health issue, addressing the opioid epidemic requires an “all-in public health approach,” according to Patrice A. Harris, MD, MA, a psychiatrist who is also the chair of the American Medical Association (AMA)’s Task Force to Reduce Opioid Abuse. The task force was created once the AMA realized the impact of the efforts across the country to reverse the epidemic.
“We thought that by working together and convening this task force, we could have a greater impact,” Harris said. “We could further amplify the ongoing efforts.”
The task force came up with 5 initial recommendations regarding education, training, use of state prescription drug monitoring programs, conversations around the issue of stigma, and raising the level of awareness of the importance of naloxone.
There are a great number of efforts taking place across the country—at both the federal and state levels and among a variety of stakeholders, including physicians, patients, families, and law enforcement—to address the opioid epidemic and to reduce opioid addiction in the United States.
On the federal level, Congress passed the Comprehensive Addiction and Recovery Act (CARA) in 2016. CARA expands access to addiction treatment services and overdose reversal medications and includes provisions that addresses care, from primary prevention to recovery support, for people with addiction.
New Jersey Governor Chris Christie just signed the country’s strictest treatment mandates for opioid addiction. The legislation included a 5-day limit on the first prescription, which is the tightest limit in the United States.
In Harris’ state of Georgia, lawmakers are putting even more of the burden on physicians. A controversial new bill would make it a crime for doctors to ignore suspicious opioid prescriptions. The Atlanta Journal-Constitution reported4 that doctors would be required to register with a state database, and those who intentionally don’t use the database or ignore the information in it could be charged with a crime. Doctors in palliative care would be exempt.
Nevertheless, Georgia is making strides to address the opioid epidemic head on: the state has an executive order to make naloxone, which is used to treat overdoses in emergency situations, widely available. First responders are encouraged to carry naloxone, according to Harris.
Vermont has also passed legislation to increase access to naloxone. The state passed a Good Samaritan law so anyone could administer naloxone without fear of facing legal repercussion.
“All of our emergency medical providers, our first responders, carry naloxone,” Cimaglio said. “We’ve trained most of the law enforcement entities around the state—many of them carry naloxone. We have pharmacies able to sell it over the counter without a prescription” due to a standing order from the state’s health commissioner.
However, the uptake of naloxone as a rescue medication does not mean there is a plan in place to address what should occur after the rescue happens, Clark said.
“Too often there is no treatment available in the community for the ongoing medication treatment; there is, unfortunately, not an understanding of what quality care should be and how to ensure that is available in the community,” she said. “So we have people who are receiving multiple rescues because there is no way for them to stay sober in their community with appropriate medical care.”
Cherokee may have found a way to address the issue. The health system employs an integrated model of care that combines both primary care and behavioral healthcare, as well as an addiction medicine program. In other cases, people go to a clinic and are treated with buprenorphine with naloxone (Suboxone), and that’s it, McGrail said.
“They don’t get the behavioral therapy,” McGrail said. “They don’t get their primary care needs met. So someone who has chronic pain, who is self-medicating pain with opiates and is now on Suboxone, that doesn’t mean their pain goes away.” Their chronic pain still needs to be addressed, and that’s what Cherokee’s integrated approach does, he added.
The Challenges of Prescribing Buprenorphine
One of the medication treatments for opioid addiction is buprenorphine, another narcotic. Currently, there is a cap on how many patients a physician can prescribe buprenorphine to. In order to be able to prescribe buprenorphine to treat addiction, a physician must complete training and receive a waiver from the Drug Enforcement Administration. In the first year after physicians receive the waiver, they can treat up to 30 patients, and in the next year they can prescribe to up to 100 patients; after that, they can prescribe to up to 275 patients a year.
Vermont helps physicians complete the requirement to obtain the waiver through a model that has online training with an experienced physician who is available to answer questions. To expand access to care, the state created a hub-and-spoke model of treating substance abuse. Each region of the state has a specialty clinic that functions as the “hub” location, and additional providers in the community that serve as the “spokes” and can provide additional medication-assisted treatment, such as buprenorphine or methadone. This has doubled the number of people receiving medication-assisted treatment since 2012, Cimaglio said.
“We feel we’re pretty close to meeting the demand, and that’s what I’m most proud of, because if people can’t get help, they’re not going to get better,” she said. “I would say that and having naloxone widely available to keep people alive have been our major accomplishments.”
Tennessee still doesn’t have a large number of people healthcare professionals who can prescribe buprenorphine, said McGrail. There are not many providers in the Knoxville area who can prescribe buprenorphine other than Cherokee Health System. And of those who do have a waiver to prescribe the medication, few are willing to care for the under- and uninsured patients that Cherokee treats.
Harris and the AMA have advocated for increasing the cap on buprenorphine prescriptions so physicians can see and treat more patients. ASAM is also in favor of increasing the cap, although Clark noted that increasing access might result in states curbing utilization given that it is not a cheap medication.
“We have a political understanding at this moment that pressing to increase that cap would likely lead to decreased access in the reality of the marketplace,” she said. “So we are working very diligently to help states, localities, the criminal justice system, [and] employer purchasers understand what is really at stake with improving access to buprenorphine.”
Until then, the cap on buprenorphine to treat opioid addiction remains an oddity, since no other prescription drugs have such a restriction.
“This cap, obviously, is highly unusual and stigmatizing around the disease of addiction,” Clark said.
The Disappearing Stigma of Addiction
Historically, society has viewed people with brain diseases, such as addiction and even epilepsy and Parkinson’s, as having a character flaw, a moral weakness, or even as being cursed or possessed. Views on psychiatric disorders changed decades ago, but it is only now that people are starting to understand that addiction should be included among more common chronic brain disorders, explained Clark.
While there has been some advancement fighting the stigma surrounding substance abuse disorder and addiction, Clark believes that there is still a long way to go.
“One of the problems with the stigma around addictive disease is that there is an outdated concept that addiction is a behavioral problem, an acute problem, that people need to just deal with their underlying issues, pull themselves up by their bootstraps, learn better coping skills, stay away from their bad friends, and just morally deal with their issues,” Clark said.
As a chronic brain disease, addiction needs to be treated and dealt with like other chronic illnesses. However, Clark still hears people wondering when someone can graduate from treatment or how long until an addict can get over his or her issues.
One of the first steps in reducing stigma around addiction is awareness, Harris said. Increased coverage by the media has helped, added McGrail. One of the clearest signs that some of the stigma has disappeared is that the people McGrail treats through Cherokee are spreading the word about treatment.
“They wouldn’t be spreading the word about treatment if they didn’t want people to know they have the disease,” he said. “So, to me, that tells me some of the stigma is starting to decrease.”
1. Use of opioid recovery medications: recent evidence on state level buprenorphine use and payment types. IMS Health website. http://www.imshealth.com/en/thought-leadership/quintilesims-institute/reports/use-of-opioid-recovery-medications. Published September 2016. Accessed February 13, 2017.
2. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445-1452. doi: 10.15585/mmwr.mm655051e1.
3. Armstrong, D. Secret trove reveals bold ‘crusade’ to make OxyContin a blockbuster. STAT website. https://www.statnews.com/2016/09/22/abbott-oxycontin-crusade/. Published September 22, 2016. Accessed February 28, 2017.
4. Hart A. Controversy flares over Georgia Senate bill to curb opioid epidemic. The Atlanta Journal-Constitution website. http://www.myajc.com/news/state--regional-govt--politics/controversy-flares-over-georgia-senate-bill-curb-opioid-epidemic/1DnOJkpCglWQH0KKeua3JN/. Published February 9, 2017. Accessed February 13, 2017.